Myopia Control: Which Form is Best?

Rory,* a 10-year-old male recently diagnosed with myopia presented. His older sister, Jennifer,* aged 16, had been attending the practice for orthokeratology (OK) management for myopia control. Fortunately, over the three years she had been attending the practice, her myopia and axial lengths had been stable. Their mother was keen for Rory to also initiate OK given his sister’s success.

Both Rory and Jennifer have autism spectrum disorder. Jennifer had been quite distressed with the initial discomfort of wearing rigid contact lenses but this was short lived. After consoling and a lengthy contact lens tuition session, she demonstrated fantastic success and was an exceedingly compliant patient, as she was motivated to not wear spectacles and understood the implications of her myopia.

Rory, on the other hand, being younger and much less mature than his sister at the outset, refused anyone or anything near his eyes, and after a couple of unsuccessful sessions involving tantrums, other options were discussed.

Rory was prescribed with HOYA MiyoSmart spectacles, which incorporate the defocused incorporated multiple segment (DIMS) technology with his prescription of R -2.25/ -0.50×175, L -2.50/-0.50×180. His initial axial lengths were R 24.21 mm; L 24.25 mm.

Six months later, Rory had exhibited mild progression to R -2.50/-0.75×176; L -2.75/ -0.75×2. His axial lengths were R 24.43 mm; L 24.55 mm.

He had been compliant in wearing his spectacles full time, however he liked wearing them lower down on his face. When they were positioned properly, the optical centres were aligned, however when he wore them in his preferred position, the optical centres were 4 mm lower than his pupils. His mother was still very keen on OK but after a firm discussion with Rory about the importance of wearing his spectacles correctly, backed with the threat of orthokeratology, he continued on for the next two years with no refractive progression.

SECRET NON-COMPLIANCE

Chris,* a 16-year-old male presented. He had a family history of myopia (his father was approximately -1D and his mother -3D). A reserved teenager; he spoke few words. He reported no problems with his eyes but was going to apply for his learner’s driving licence and his parents wanted to ensure he could see well enough for driving.

Chris had a refraction of R -1.25/-0.25×143; L -1.25DS.

Although his refraction was low, his axial lengths were relatively long being R: 25.43 mm, L: 25.03 mm.

After a lengthy discussion and explaining the implications, especially given the increased risk of irreversible sight loss, Chris and his parents were keen to pursue myopia control. Refractive options were discussed, and they decided to proceed with OK.

Chris struggled with the contact lens tuition. He found the lenses to be extremely uncomfortable, however after some time he was successfully able to apply and remove the lenses. He was sent home and reviewed the next day.

At the review appointment the next day, Chris’ vision unaided was R and L 6/7.5=. He was reviewed at one week, and then at one month, and demonstrated success at these appointments. At the three-month review, his vision unaided was R and L 6/9+. Refraction was R -1.25/-0.25×11 (6/6); L -1.50/-0.25×180 (6/6).

However, his axial lengths had not changed. Over-refraction with the contact lenses was plano (which was also found at the delivery appointment). Corneal topography revealed under-treatment. Examination of the lenses revealed they were well fitting and in good condition. Chris reported that he had been compliantly using the lenses, however after some gentle probing, it was evident that he had not been wearing them consistently.

His parents said they would supervise him more closely, and at the next six-monthly review his unaided vision was R and L 6/6 and his axial lengths stable.

Six months later, he returned for his review, aged 17 and completing his final year of high school. Vision unaided was 6/24, L 6/24=; binocularly 6/15=.

Refraction was R -1.75DS (6/6); L -1.50DS (6/6).

Axial lengths were R 25.69; L 25.25 mm.

Corneal topography revealed almost no OK treatment. Examination of the lenses revealed they were well fitting and there was no over-refraction.

Chris insisted that he had been compliant with wearing the OK lenses. However, after a gentle discussion without his parents in the room, he admitted that he hated wearing the lenses but had been too afraid to admit it. His parents were alarmed to hear that he had been driving a car while not meeting the visual requirement for driving. Other options were presented, and he was happy with the spectacle lens option. HOYA MiyoSmart lenses were prescribed.

He wears them compliantly, and his axial lengths and refraction have been stable since.

A TAILORED APPROACH

So, what is the best myopia control modality?

When tackling myopia, it is important to have more than just one trick up your sleeve. It is essential to tailor the approach based on the individual. The effectiveness of different myopia management techniques can vary, however what works best for one person may not be suitable for another.

It’s important not to put patients into predefined boxes and prescribe the one you like the most because if your patient won’t comply with your treatment, your treatment will not work.

We also have to remember that these patients we are prescribing myopia control to are young, still finding their place in the world, and often fragile. Forcing a treatment onto an unwilling user may lead to them not being honest about their compliance, or even cause some degree of trauma. This may then close all future opportunities to arrest their myopia.

Moreover, as we acquire most of the information we need through our eyes, inability or difficulty to see can be detrimental to a young person’s learning and development. It can even be dangerous, as was the case with Chris, who would rather drive his parents’ car illegally than be honest about his dislike of wearing OK lenses.

NO NOW OR NO FOREVER?

Saying no to a treatment now also does not impede that treatment being a treatment option in the future, so a ‘no now’ shouldn’t be perceived as a ‘no forever’, it should be a ‘no, not now’. Discussing the options at each visit can familiarise an unknown ‘scary’ thing and as the patient grows and matures, their individual motivation and desires may change and they may come around to other options.

These two cases also highlight the importance of regular reviews, and the need to understand the intricacies of how the techniques work. If a treatment is not working, it is imperative that we first assess whether the treatment is used properly. Blaming the treatment and re-prescribing treatment that is not used adequately to be used in the same way will end up with similar results.

It would appear that employing myopia management with techniques such as OK, CooperVision MiSight, HOYA MiyoSmart, and Essilor Stellest technology will reduce myopia progression by around half,¹ however anecdotally in practice, many of the patients we prescribe these products for will arrest myopia progression completely.

Patients undergoing myopia control should be actively involved in the decision-making process. Engaging the patient in selecting a technique they are comfortable with can greatly improve compliance. While options like OK can be effective, they may not be suitable for everyone. Therefore, the decision should not be entirely practitioner or parent driven, especially now that we have multiple great options and probably more to come on the horizon.

We are lucky now that we can offer a variety of myopia control treatment modalities. By considering individual needs, preferences, and ensuring a collaborative decision-making process, we can work together to reduce the progression of myopia effectively and promote long-term eye health.

So, what is the best modality for the patient? The one that they will wear (compliantly).

*Patient names changed for anonymity.

Jessica Chi is the Director of Eyetech Optometrists, an independent specialty contact lens practice in Melbourne. She is the current Victorian, and a past National President of the Cornea and Contact Lens Society, and an invited speaker at meetings throughout Australia and beyond. She is a clinical supervisor at the University of Melbourne, a member of Optometry Victoria Optometric Sector Advisory Group and a Fellow of the Australian College of Optometry, the British Contact Lens Association, and the International Academy of Orthokeratology and Myopia Control.

Reference

1. Brennan, N.A., Toubouti, YM, Cheng, X., Bullimore, M.A., Efficacy in myopia control. Prog Retin Eye Res. 2021 Jul;83:100923. DOI: 10.1016/j.preteyeres.2020.100923.